Mediastinal/Bronchial Mass Should Merit Admission to ICU

Patients present with shortness of breath, worsening over the last few days/weeks. Upon further testing – CT scan, MRI, x-ray – are found to have a mediastinal or bronchial mass. They are admitted to the inpatient oncology unit for biopsy and to begin appropriate treatment. This is a situation I have seen far too often lately. The problem with these patients is they are not stable.

In my most recent experience, two out of three patients ended up in ICU on my watch prior to biopsy and, of course, treatment. This leads me to wonder if these patients should be admitted to ICU and stay there until treatment can begin. Here is just a small sampling of my three most recent patients.

Patient A is a female in her mid-50s. She was scheduled for biopsy on three separate days across the span of a week. Each time her biopsy was put off due to coagulopathy. I admitted this patient from the office and had her two or three more days while she was awaiting biopsy. That last day I had her, I came in and noticed she was very confused and just not making sense at all. Luckily, her oncologist was on the floor at the time I went in her room, so I went and asked him his opinion and stated that she was definitely just “not right”. This doctor went back in to see the patient, walked out and asked that I call the pulmonologist following her while he called the surgeon. He was on the phone with the surgeon and angry so quickly, I was proud of him. Within 10 minutes, 4 more doctors had come and seen this patient and determined she was not stable and needed an immediate transfer to ICU until she could get a biopsy, which would hopefully happen the following day. Within minutes of being in ICU, the patient was intubated, no longer breathing on her own. In this situation, I was very happy I trusted my gut and that the doctor was there. I was applauded by several other staff members that day for the steps we took to get her safer treatment – insisting the doctor go see her again.

Patient B was a man in his mid-60s. I received him as an admit from the office, where he was seen for another chronic problem. When he arrived to his room, no family was at his side and he could not answer any questions I asked him – not even simple yes/no questions. I found he was severely hypoxic, placed him on a nasal cannula, titrating up to 6 L/min just to get him to 80% spO2. I called the doctor admitting him to explain how hypoxic he was and had another coworker call the respiratory therapist for further oxygen treatment. With a high-flow nasal cannula, we were able to get the patient to the mid-80%s. He started answering some simple questions, but kept trying to get out of bed – you know, that restlessness everyone gets when their oxygenation is low.

Upon admission, the Patient B was also very hypotensive. Beofre the admitting physician was up to see the patient, he had me bolus the patient to see if this helped hemodynamically. He was up to see the patient around the time the bolus was finishing. I rechecked the patient’’s blood pressure and found it to be lower, not higher. The MD consulted pulmonology while he worked on his admit orders. The subsequent 3 hours consisted of the two MDs disagreeing on what this patient needed – one said another bolus, one said the patient was simply third spacing the fluid so we were doing him no good by pushing fluids. By 1845, the patient had me so nervous I called the on call for the admitting doctor, explained the situation, and was told, “He needs to be in ICU. Call the pulmonologist and tell him this.” I called the pulmonologist. Luckily he agreed that the patient merited immediate transfer, but for different reasons. I don’t know what ever came of this patient, except that he was not readmitted to our unit while I was there.

Patient C was the good patient. He was young – mid-20s. Presented with a mediastinal mass  and difficulty breathing. He was on a venti mask per his request – it made him feel like he was breathing more easily. Unlike the other patients, he got his biopsy within a day of admission. His treatment was able to begin just a couple days later and he walked out a week later.

What I just can’t get past is why Patient A was made to suffer for several days instead of trying to reverse her coagulopathy and why was Patient B ever admitted to a medical unit? It is not safe, in my opinion, to keep these patients on a medical unit where they are cared for under higher ratios. In ICU, the nurses have one to three patients, depending on condition. On the oncology unit, we have a minimum of three patients, moreso depending on staffing, not acuity. In the situations of Patient A and Patient B, on the day they transferred to ICU, I spent no less than 3 hours dealing with their issues, all the while trying to juggle two to three other patients. I don’t put this fault on my management. I put this fault on the policies for admission to ICU, the doctors who don’t want to admit someone. I’m fairly certain all patients had favorable outcomes, but I don’t know. And what could have happened leads me to believe that any patient admitted with a mediastinal or bronchial mass requiring oxygenation and showing signs of confusion should automatically be admitted to ICU for their own safety.